Provider Demographics
NPI:1790084028
Name:TIBBETT, JASON (CRNA)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:TIBBETT
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5887
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71307-5887
Mailing Address - Country:US
Mailing Address - Phone:870-735-1500
Mailing Address - Fax:870-733-3861
Practice Address - Street 1:200 TYLER ST
Practice Address - Street 2:
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301
Practice Address - Country:US
Practice Address - Phone:870-735-1500
Practice Address - Fax:870-733-3861
Is Sole Proprietor?:No
Enumeration Date:2011-03-25
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP07594367500000X
TN169954367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
169954OtherTN LICENSE